Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial

OBJECTIVE: To evaluate the effect of early optimization in the survival of severely injured patients. SUMMARY BACKGROUND DATA: It is unclear whether supranormal ("optimal") hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. METHODS: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. RESULTS: Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference in rates of death (15% optimal vs. 11% control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. CONCLUSIONS: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.     

Mechanisms for Cachexia in Heart Failure

The combination of profound muscle wasting and severe weight loss that occurs in heart failure is a complex phenomenon that involves the interplay of numerous factors. In this article, we describe processes that contribute to cachexia, as part of the clinical sequelae of heart failure, and their potential underlying mechanisms. While multiple mechanisms of cardiac cachexia have been described, we propose a multifactorial etiology for this condition that includes, but is not limited to, nutritional and gastrointestinal alterations, immunological and neurohormonal activation, and anabolic and catabolic imbalance.     

Efficacy of benfluorex in combination with sulfonylurea in type 2 diabetic patients: an 18-week, randomized, double-blind study

OBJECTIVE: The aim of this study was to demonstrate the superiority of benfluorex over placebo as an add-on therapy in type 2 diabetic patients in whom diabetes is insufficiently controlled by sulfonylurea monotherapy and who have a limitation for the use of metformin. RESEARCH DESIGN AND METHODS: Type 2 diabetic patients with HbA(1c) (A1C) (7-10%) who were receiving the maximum tolerated sulfonylurea dose and had a contraindication to or poor tolerance of metformin were randomly assigned (double blind) to receive benfluorex 450 mg/day (n = 165) or placebo (n = 160) for 18 weeks. The main efficacy criterion was A1C, analyzed as the change from baseline to the end of treatment using ANCOVA with baseline and country as covariates. Secondary criteria were fasting plasma glucose (FPG), insulin resistance, and plasma lipid level. RESULTS: Both groups were similar at baseline in the intention-to-treat population. A1C significantly decreased with benfluorex from 8.34 +/- 0.83 to 7.52 +/- 1.04% (P < 0.001) and tended to increase with placebo from 8.33 +/- 0.87 to 8.52 +/- 1.36% (NS), resulting in a mean adjusted difference between groups of -1.01% (95% CI -1.26 to -0.76; P < 0.001). The target A1C (< or =7%) was achieved in 34% of patients receiving benfluorex versus 12% of patients receiving placebo. Significant between-group differences in favor of benfluorex were observed for mean FPG (-1.65 mmol/l) (P < 0.001) and for homeostasis model assessment of insulin resistance. Overall tolerance was similar in both groups. Serious adverse events were more frequent in the benfluorex group, without evidence of causality relationship. CONCLUSIONS: Benfluorex as an add-on therapy was superior to placebo in lowering A1C with a between-group difference of 1% in type 2 diabetic patients whose disease was insufficiently controlled with sulfonylurea alone and in whom metformin was contraindicated or not tolerated.     

Intravascular lymphoma associated with haemophagocytic syndrome: a very rare entity in western countries

Intravascular lymphoma (IVL) is a rare and aggressive disorder, characterised by frequent cutaneous and neurological involvement and medullary infiltration. In rare cases particularly in Asia, IVL can be associated with haemophagocytic syndrome (IVL-HS). Here, we report the case of a 61-year-old Caucasian female who presented with IVL-HS. Bone marrow biopsy showed haemophagocytic features and medullary localisation of a diffuse large B-cell lymphoma. Liver biopsy showed exclusive sinusoidal infiltration by large B cells. Treatment by polychemotherapy associated with rituximab induced a rapid complete remission. Unfortunately, death occurred as a consequence of septic shock. Early recognition of IVL-HS by performing bone marrow biopsy is critical to start rapidly appropriate treatment. The role of rituximab in the management of IVL-HS remains to be established.     

Effect of high-dose steroids on anastomotic complications after proctocolectomy with ileal pouch–anal anastomosis

This review was designed to determine whether “high-dose” steroid therapy (≥20 mg prednisone/day) increases the likelihood of anastomotic complications after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The hospital records of 100 patients undergoing proctocolectomy with IPAA were reviewed. Patient characteristics were analyzed to determine what factors were associated with higher rates of anastomosis-related complications. Seventy-one of our patients were given diverting ileostomies, whereas the remaining 29 underwent a single-stage procedure. Fifty-four percent of the patients in our review were taking steroids preoperatively, 39 of whom were on high-dose therapy. The overall anastomosis-related complication rate was 14%. There was no significant difference in complication rates with respect to age, steroid use, steroid dose, use of a diverting ileostomy, type of anastomosis, duration of disease, or presence of backwash ileitis. A trend toward higher leakage rates was found in patients undergoing single-stage procedures (10.3% vs. 2.8%, P = 0.14) as well as in patients undergoing single-stage procedures on high-dose steroids (22% vs. 5.0, P = 0.22). Nevertheless, neither of these trends was found to be statistically significant, which was likely infiuenced by the small sample size. Our data suggest that there may be an increase in anastomotic leakage rates in patients on high-dose steroids undergoing a single-stage proctocolectomy with IPAA. Nevertheless, our rate was not as high as the rates seen by other investigators and did not reach statistical significance. During preoperative counseling, patients on high-dose steroids should be informed of this uncertain but real risk of anastomotic leakage.     

Hemophagocytic syndrome as a presenting sign of transformation of smoldering to acute adult T-cell leukemia/lymphoma: efficacy of anti-retroviral and interferon therapy

A 55-year-old Caribbean woman with a 6-year history of smoldering adult T-cell leukemia/lymphoma presented with clinical and biological symptoms of hemophagocytic syndrome. An extensive search for infectious diseases was negative. A lymph node biopsy showing large T-cell lymphoma (CD4-, CD25+) and findings of high LDH count and severe lymphocytosis led to the diagnosis of acute adult T-cell leukemia/lymphoma. Anti-retroviral therapy combining zidovudine, lamivudine, and interferon-alpha was started, resulting in rapid control of both hemophagocytic syndrome and symptoms of acute adult T-cell leukemia/lymphoma. Thus, we propose that adult T-cell leukemia/lymphoma must be added to the spectrum of etiologies of hemophagocytic syndrome.     

Histological features of cutaneous secondary syphilitic lesions: a report of two cases

Syphilis is a sexually transmitted infectious disease, which currently shows a high increase of incidence in HIV negative patients. These patients often seek medical advice at a stage of secondary syphilis, as the lesions of the primary phase may pass unperceived. Very often, the diagnosis is evoked through a cutaneous biopsy, since the clinical presentation is often misleading. Even though the histological signs are not specific, they may suggest the diagnosis, by showing a psoriasiform epidermal hyperplasia with neutrophil exocytosis and a dermal lichenoid infiltrate rich in plasma cells. However, it is important to underline the great polymorphism of these lesions, which can easily vary according to the stage and /or clinical form. It's very important to have a quick and accurate diagnosis, because the lesions are very contagious, but rapidly and completely cured by an early administrated antibiotic treatment.     

"Insignificant" mechanism of injury: not to be taken lightly

BACKGROUND: Trauma resources should be spent rationally. The mechanism of trauma is used extensively to triage patients to appropriate levels of care. We examine the hypothesis that patients with "insignificant" mechanism of trauma may have major injuries that require expert trauma care. STUDY DESIGN: Over 9 months at a high-volume Level I trauma center, a prospective study was done on patients who sustained ground-level falls (GLF), low-level falls (LLF) from less than 10 feet, or were found down (FD) with no external evidence of significant trauma, and required evaluation by the trauma team. Of 301 patients included, 110 (37%) had GLF, 95 (31%) LLF, and 96 (32%) FD. Our main outcomes measure was significant injuries, defined as visceral or intracranial injuries, long-bone, pelvic, facial, or spinal fractures. RESULTS: One hundred ten patients (37%) had significant injuries, 20 (7%) were admitted to the ICU, 14 (5%) required an operation, and 4 (1%) died. The most common injuries were intracranial and skeletal. Almost all patients were evaluated by CT (95%), but only one-quarter had abnormal findings on it. LLF, age more than 55 years, and the absence of severe intoxication (blood alcohol level of less than 200 mg/dL) were independent risk factors for significant injuries. A statistical prediction model showed that, when all risk factors are present, the probability of significant injuries is 73%; when all risk factors are absent, there is still a 16% chance for significant injuries. Patients with significant injuries had more operations, longer hospital stays, and higher hospitalization costs compared with patients without significant injuries. CONCLUSIONS: Low-energy trauma may produce significant injuries, predominantly intracranial and skeletal. Trauma care providers should be cautious about dismissing such patients based on the trivial mechanism of injury. Patients with LLF who are older than 55 years and not severely intoxicated have a high likelihood for significant injuries. Resources should be spent rationally for patients who do not have these characteristics, because the probability of significant injuries among them is low, but not zero.     

Influence of flail chest on outcome among patients with severe thoracic cage trauma

Flail chest is associated with a higher morbidity compared with multiple rib fractures, and it requires early intubation. This was a prospective comparative uncontrolled study at an academic level 1 trauma center. Twenty-two patients with flail chest (FLAIL) were compared with 90 patients with more than two rib fractures but no flail chest (RIBS) to determine differences in outcomes such as mortality, significant respiratory complications (pneumonia and adult respiratory distress syndrome), need for mechanical ventilation, and length of hospital stay. Stepwise logistic regression identified independent risk factors of poor outcome. Despite similar age and rates of lung contusion and extrathoracic injury, FLAIL patients had a higher need for mechanical ventilation (86% versus 42%, P < 0.01), higher incidence of significant respiratory complications (64% versus 26%, P < 0.01), and longer hospital stay (28 +/- 21 versus 17 +/- 19 days, P = 0.04) compared with RIBS patients. Flail chest and extrathoracic injuries were independent risk factors of significant respiratory complications. Of 11 FLAIL patients who were not intubated on arrival, eight required intubation within the next 24 hours, often while receiving diagnostic studies in poorly monitored hospital areas; two of these patients suffered morbidity directly related to the delay in intubation. Three patients without associated injuries were managed successfully without intubation. Flail chest is an independent marker of poor outcome among patients with thoracic cage trauma. The majority of patients with flail chest need mechanical ventilatory support and develop significant respiratory complications. In the presence of associated injuries, intubation is unavoidable and should be done under controlled conditions early after arrival to avoid morbidity related to sudden respiratory decompensation.